Healthcare Provider Details

I. General information

NPI: 1487680757
Provider Name (Legal Business Name): LICERIO S SOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL RD
WHITESBURG KY
41858-7627
US

IV. Provider business mailing address

240 HOSPITAL RD
WHITESBURG KY
41858-7627
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-3500
  • Fax: 606-633-3652
Mailing address:
  • Phone: 606-633-3500
  • Fax: 606-633-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number23887
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: